Antibiotic Resistance and the Cost of Doing Nothing

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1 Antibiotic Resistance and the Cost of Doing Nothing PIERO GARZARO, MD REGIONAL CHIEF OF INFECTIOUS DISEASES THE PERMANENTE MEDICAL GROUP NORTHERN CALIFORNIA

2 About Kaiser Permanente Serves 10 million patients in the US. Located in 8 states More than 40 hospitals and 600 clinics/medical offices. Integrated system of providers (MD, RN, PharmD, Insurance Plan all under one roof). Electronic Medical record developed for KP which allows for standardized order entry, documentation, coding, clinical alerts, etc.

3 Good antimicrobial stewardship is the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment of infection with minimal toxicity to the patient and minimal impact on subsequent resistance. Gerding DN. Joint Commission Journal on Quality Improvement. 2001; 27:

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5 THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. Section is added to the Health and Safety Code, immediately following Section , to read: Each general acute care hospital, as defined in subdivision (a) of Section 1250, shall do all of the following by July 1, 2015: (a) Adopt and implement an antimicrobial stewardship policy in accordance with guidelines established by the federal government and professional organizations. This policy shall include a process to evaluate the judicious use of antibiotics in accordance with paragraph (3) of subdivision (a) of Section (b) Develop a physician supervised multidisciplinary antimicrobial stewardship committee, subcommittee, or workgroup. (c) Appoint to the physician supervised multidisciplinary antimicrobial stewardship committee, subcommittee, or workgroup, at least one physician or pharmacist who is knowledgeable about the subject of antimicrobial stewardship through prior training or attendance at continuing education programs, including programs offered by the federal Centers for Disease Control and Prevention, the Society for Healthcare Epidemiology of America, or similar recognized professional organizations. (d) Report antimicrobial stewardship program activities to each appropriate hospital committee undertaking clinical quality improvement activities.

6 Process Map for Antimicrobial Stewardship Antimicrobial Stewardship IDP Reviews Medici Program ID Pharmacist (IDP) reviews patients of interest, shared lists, and personal list daily using Medici Program to assess appropriateness of Antimicrobial Therapy Broad Spectrum antibiotics, double anaerobic coverage, vancomycin IV >72h duration, ID f/u list (all shared) Antimicrobials IDP Documents in Medici Includes Intervention Plan IDP Compiles Patients Eligible for Intervention Patient Case Closed No Are Antimicrobials Appropriate? Yes IDP documents in Medici Other IDPs will be able to see documentation** Does patient case need to be reviewed again?* No IDP documents in Medici that No Intervention Deemed Necessary** IDP Reviews Cases and Proposed Interventions with ID MD With full patient presentation if necessary No Is Intervention Necessary? Yes ID MD or IDP contacts Physician (attending, resident, fellow, etc.) or Practitioner (NP, PA, etc.) to discuss Therapy IDP ID MD Yes IDP documents in Medici & Places Patient in ID Follow Up List Indicating case to be reviewed again at a given time interval ID Follow Up List Pt A: review xx/xx/xx Pt B: review xx/xx/xx Pt C: review xx/xx/xx Pt D: review xx/xx/xx IDP documents in Medici Intervention Not Accepted** FOOTNOTES: * There is outstanding or pending information (microbiology, radiology, susceptibilities, other laboratory values) that is necessary to complete assessment of patient s antimicrobial therapy. This needs to be followed up by IDP. ** Antimicrobial therapy may be reassessed at a later point based on duration of therapy, change in status, addition of antimicrobials or other clinical event. No Is Intervention Accepted? Yes IDP documents discussion in Medici. Written order is placed by Practitioner if necessary. Verbal order can be taken by IDP. Patient is followed by IDP for 3-5 days postintervention to ensure satisfactory course 6 6

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8 So What is the Business Case? 20-30% overuse of antimicrobials costs $ Inventory costs Administration costs Treatment of drug resistant organisms cost $ CDI rates HAI MRSA, ESBLs Prolonged IV when switch to PO is possible costs $ Increased LOS Need to explain this program requires ongoing maintenance

9 Prior Authorization at KP Antimicrobial formulary developed with the input of the Regional ID Chiefs Allows for approval with guidelines or restrictions Very few antimicrobials require up front ID approval Electronic order entry sets for pneumonia, intraabdominal infection, UTI, etc. Developed using input from stakeholder chiefs groups and national/specialty guidelines Electronic decision support provided at time of order entry

10 ASP Protocol for Prospective Audit/Feedback Screening: Pharmacist surveys antimicrobial report Originally by line listing Using EMR and data mining 2008 Pre-rounding: Pharmacist reviews hx, allergies, labs (WBC/Creat Cl), radiology, micro Rounding: Presentation to ID physician Intervention: Contact attending MD (Phone/Paper/ ) Follow-up: patient is followed daily until discharge Electronic review of notes/vital signs/labs/cultures Additional intervention as needed

11 Guidelines Example

12 Decision Support Example

13 We can compare ourselves with rest of the Nation

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15 Sustained Decrease in Abx Use Anti-pseudomonal Carbapenem Fluoroquinolone Narrow Spectrum Vancomycin Year Defined Daily Doses of Targeted Antimicrobial Classes per 100 patient admissions. Carbapenem, antipseudmonal, and fluoroquinolone ABX decreased over the intervention period. Vancomycin initially decreased but increased in Narrow spectrum ABX DDD increased after ASP.

16 Kaiser NorCal Interventions Jan-July 2015

17 ASP: Doing the Right Thing Dellit TH et al. Clinical Infectious Diseases. 2007; 44:

18 Food for thought In 2003 KP had a budget of $186 million for infectious disease drugs. In 2009 the budget was $280 million. By 2013 this had increased to over $300 million.

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20 Questions?